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Older adults experiencing acute pain are often underassessed and undertreated. This review summarizes recommendations from an evidence-based practice guideline on acute pain management in older adults. Key areas highlighted are pain assessment and monitoring, patient education, pharmacologic management, and nonpharmacologic management. [ABSTRACT FROM AUTHOR]

Background: We developed a remote cardiovascular risk service (CVRS) managed by clinical pharmacists to support primary care teams. The purpose of this study was to examine whether the CVRS could improve guideline adherence in primary care clinics with diverse geographic and patient characteristics., Methods: This study was a cluster-randomized trial initiated in 20 primary care clinics across the US. Clinics were stratified as high or low minority and then randomized to receive the intervention or maintain usual care for 12 months. The primary outcome was adherence to relevant The Guideline Advantage (TGA) criteria met. TGA is a compilation of criteria from practice guidelines intended to improve the quality of primary care. Post-hoc outcomes included changes in individual TGA measures., Results: A total of 401 study subjects were included in the analysis. Mean TGA scores remained the same in the intervention group (n=193, 0.72) and slightly decreased in the usual care group (n=208, 0.67 to 0.66) over the 12-month study period. There was no significant difference between the mean TGA scores in intervention and usual care groups for the overall population at 12 months (0.72 versus 0.66 respectively, p=0.10). For under-represented minority subjects, there was no significant difference between TGA scores at 12 months (n=186; 0.70 versus 0.67, respectively, p=0.50). In a post-hoc analysis of subjects uncontrolled at baseline, there was a significant improvement in systolic BP at 12 months in the intervention group versus usual care (model-based difference of -8.03mmHg, p=0.03)., Conclusions: Improvements in individual TGA measures were limited, in part, due to higher than expected baseline TGA scores. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events., Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02215408; https://clinicaltrials.gov/ct2/show/NCT02215408?id=NCT02215408.

Background: Numerous studies have demonstrated the value of including pharmacists in team-based care to improve adherence to cardiovascular (CV) guidelines, medication adherence, and risk factor control. However, there is limited information on whether these models can be successfully implemented more widely in diverse settings and populations. The purpose of this study is to evaluate whether a centralized, web-based cardiovascular risk service (CVRS) managed by clinical pharmacists will improve guideline adherence in multiple primary care medical offices with diverse geographic and patient characteristics., Methods: This study is a prospective trial in 20 primary care offices stratified by the percent of under-represented minorities and then randomized to either the CVRS intervention or usual care. The intervention will last for 12 months and all subjects will have research visits at baseline and 12 months. The primary outcome is the difference in guideline adherence between groups. Data will also be abstracted from the medical record at 24 months to determine if the intervention effect is sustained after it is discontinued., Conclusions: Patient enrollment will continue through 2016, with results expected in 2019. This study will provide information on whether a distant, centralized CVRS can be implemented in large numbers of medical offices, if it is effective in diverse populations, and if there is a long-term sustained effect., (© 2015 Pharmacotherapy Publications, Inc.)

Background: The purpose of this study was to evaluate if a physician/pharmacist collaborative model would be implemented as determined by improved blood pressure (BP) control in primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control could be sustained., Methods and Results: Prospective, cluster-randomized trial of 32 primary care offices stratified and randomized to control, 9-month intervention (brief), and 24-month intervention (sustained). We enrolled 625 subjects with uncontrolled hypertension; 54% from racial/ethnic minority groups and 50% with diabetes mellitus or chronic kidney disease. The primary outcome of BP control at 9 months was 43% in intervention offices (n=401) compared with 34% in the control group (n=224; adjusted odds ratio, 1.57 [95% confidence interval, 0.99-2.50]; P=0.059). The adjusted difference in mean systolic/diastolic BP between the intervention and control groups for all subjects at 9 months was -6.1/-2.9 mm Hg (P=0.002 and P=0.005, respectively), and it was -6.4/-2.9 mm Hg (P=0.009 and P=0.044, respectively) in subjects from racial or ethnic minorities. BP control and mean BP were significantly improved in subjects from racial minorities in intervention offices at 18 and 24 months (P=0.048 to P<0.001) compared with the control group., Conclusions: Although the results of the primary outcome (BP control) were negative, the key secondary end point (mean BP) was significantly improved in the intervention group. Thus, the findings for secondary end points suggest that team-based care using clinical pharmacists was implemented in diverse primary care offices and BP was reduced in subjects from racial minority groups., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077., (© 2015 American Heart Association, Inc.)

Background: Studies have demonstrated that physician/pharmacist collaboration can improve management of chronic conditions., Objective: The purpose of this study was to determine whether a correlation exists between existing clinical pharmacy services within a practice-based research network (PBRN) and provider attitudes and beliefs regarding implementing a new pharmacy intervention based on the Theory of Planned Behavior (TPB)., Methods: A validated survey was completed by one clinical pharmacist from each office. This instrument evaluated the current clinical pharmacy services provided in the medical office. TPB instruments were developed that measured beliefs concerning implementation of a clinical pharmacy intervention for either blood pressure or asthma. The pharmacy services and TPB surveys were then administered to physicians and pharmacists in 32 primary care offices throughout the United States., Results: Physicians returned 321 (35.9%) surveys, while pharmacists returned 40 (75.5%). The Cronbach's alpha coefficients generally ranged from 0.65 to 0.98. TPB subscale scores were lower in offices rated with lower pharmacy service scores, but these differences were not statistically significant. There was no correlation between clinical pharmacy service score and providers' TPB subscale scores. In both the hypertension and asthma groups, pharmacists scores were significantly higher than physicians' scores on the attitudes subscale in the multivariate analysis (P < 0.001 and P < 0.05, respectively)., Conclusions: Pharmacists consistently scored higher than physicians on the TPB, indicating that they felt the hypertension or asthma intervention would be more straightforward for them to implement than did physicians. There was no significant correlation between clinical pharmacy service scores and attitudes toward implementing a future physician/pharmacist collaborative intervention using the TPB. Future studies should investigate the ability of the TPB instrument to predict implementation of a similar intervention in offices of physicians never exposed to clinical pharmacy services., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Objective: To categorize institutional review board (IRB) challenges and solutions encountered in a multicenter practice-based research network (PBRN) study and to assess the impact of IRB requirements on the willingness of individual principal investigators (PIs) to participate in future PBRN studies., Design: Descriptive analysis of IRB challenges and solutions encountered in the Collaboration Among Pharmacists and Physicians to Improve Outcomes Now (CAPTION) trial, a multicenter prospective cluster-randomized study conducted by the National Interdisciplinary Primary Care PBRN, and a correlational analysis from a survey of individual site PIs., Measurements and Main Results: IRB barriers encountered and solutions were categorized for study sites. A survey of study-site PIs was conducted with a correlational analysis assessing the impact of various IRB requirements and the willingness of individual PIs to participate in future PBRN studies; of 31 study sites participating in the CAPTION study, 28 study-site PIs were surveyed. IRBs posed a number of challenges including bias regarding the source of the application, issues regarding study design, study instruments, access to patient records, study procedures, Spanish-only speaking subjects, role of clinic physicians, interdepartmental concerns, and updates at continuing review. Responses from the PI survey (21 of 28 PIs surveyed [75% response rate]) indicated that the willingness of an individual to serve as a PI in the future was inversely related to the perceived difficulty of obtaining initial (rS  = -0.599, p=0.004) and continuing (rS  = -0.464, p=0.034) IRB approval., Conclusion: Significant time and resources were required to address various challenges associated with IRB approval, which had a negative impact on an individual PI's willingness to participate in future PBRN projects. A revision of current rules and regulations regarding the protection of human subjects for practice-based studies, improvement in IRB processes, and support from coordinating centers may decrease the burden associated with IRB approval and increase participation in practice-based research., (© 2013 Pharmacotherapy Publications, Inc.)

This paper examines baseline characteristics from a prospective, cluster-randomized trial in 32 primary care offices. Offices were first stratified by percentage of minorities and level of clinical pharmacy services and then randomized into 1 of 3 study groups. The only differences between randomized arms were for marital status (P=.03) and type of insurance coverage (P<.001). Blood pressures (BPs) were similar in Caucasians and minority patients, primarily blacks, who were hypertensive at baseline. On multivariate analyses, patients who were 65 years and older had higher systolic BP (152.4 ± 14.3 mm Hg), but lower diastolic BP (77.3 ± 11.8 mm Hg) compared with those younger than 65 years (147.4 ± 15.0/88.6 ± 10.6 mm Hg, P<.001 for both systolic and diastolic BP). Other factors significantly associated with higher systolic BP were a longer duration of hypertension (P=.04) and lower basal metabolic index (P=.011). Patients with diabetes or chronic kidney disease had a lower systolic BP than those without these conditions (P<.0001). BP was similar across racial and socioeconomic groups for patients with uncontrolled hypertension in primary care, suggesting that patients with uncontrolled hypertension and an established primary care relationship likely have different reasons for poor BP control than other patient populations., (© 2013 Wiley Periodicals, Inc.)

The objectives of this study were to compare indices of 24-hour blood pressure (BP) following a physician-pharmacist collaborative intervention and to describe the associated changes in antihypertensive medications. This was a secondary analysis of a prospective, cluster-randomized clinical trial conducted in 6 family medicine clinics randomized to co-managed (n=3 clinics, 176 patients) or control (n=3 clinics, 198 patients) groups. Mean ambulatory systolic BP (SBP) was significantly lower in the co-managed vs the control group: daytime BP 122.8 mm Hg vs 134.4 mm Hg (P<.001); nighttime SBP 114.8 mm Hg vs 123.7 mm Hg (P<.001); and 24-hour SBP 120.4 mm Hg vs 131.8 mm Hg (P<.001), respectively. Significantly more drug changes were made in the co-managed than in the control group (2.7 vs 1.1 changes per patient, P<.001), and there was greater diuretic use in co-managed patients (79.6% vs 62.6%, P<.001). Ambulatory BPs were significantly lower for the patients who had a diuretic added during the first month compared with those who never had a diuretic added (P<.01). Physician-pharmacist co-management significantly improved ambulatory BP compared with the control group. Antihypertensive drug therapy was intensified much more for patients in the co-managed group., (© 2013 Wiley Periodicals, Inc.)

Study Objective: To compare costs associated with a physician-pharmacist collaborative intervention with costs of usual care., Design: Cost analysis using health care utilization and outcome data from two prospective, cluster-randomized, controlled clinical trials., Setting: Eleven community-based medical offices., Patients: A total of 496 patients with hypertension; 244 were in the usual care (control) group and 252 were in the intervention group., Measurements and Main Results: To compare the costs, we combined cost data from the two trials. Total costs included costs of provider time, laboratory tests, and antihypertensive drugs. Provider time was calculated based on an online survey of intervention pharmacists and the National Ambulatory Medical Care Survey. Cost parameters were taken from the Bureau of Labor Statistics for average wage rates, the Medicare laboratory fee schedule, and a publicly available Web site for drug prices. Total costs were adjusted for patient characteristics. Adjusted total costs were $774.90 in the intervention group and $445.75 in the control group (difference $329.16, p<0.001). In a sensitivity analysis, the difference in adjusted total costs between the two groups ranged from $224.27-515.56. The intervention cost required to have one additional patient achieve blood pressure control within 6 months was $1338.05, determined by the difference in costs divided by the difference in hypertension control rates between the groups ($329.16/24.6%). The cost over 6 months to lower systolic and diastolic blood pressure 1 mm Hg was $36.25 and $94.32, respectively., Conclusion: The physician-pharmacist collaborative intervention increased not only blood pressure control but also the cost of care. Additional research, such as a cost-benefit or a cost-minimization analysis, is needed to assess whether financial savings related to reduced morbidity and mortality achieved from better blood pressure control outweigh the cost of the intervention., (© 2012 Pharmacotherapy Publications, Inc. All rights reserved.)

Team-based care can improve hypertension control. The purpose of the present study was to evaluate blood pressure (BP) control 18 months following the discontinuation of a physician-pharmacist collaborative intervention. This was a retrospective analysis of patients who had previously participated in a prospective, cluster randomized, controlled clinical trial. Six community-based family medicine offices were randomized to control or intervention groups. Research nurses measured BPs using an automated device during the prospective trial. The research nurses then abstracted data from medical records, including BPs, medications, changes in therapy, and laboratory values for 18 months following the discontinuation of the 6-month prospective trial. The study included 228 patients in the control (n = 146) or intervention (n = 82) groups. The control group contained more patients with diabetes or chronic kidney disease (P < .013), were older (P = .047), and had more coexisting conditions (P < .001) than the intervention group. Systolic BP 9 months following discontinuation of the physician-pharmacist intervention was 137.2 ± 18.2 mm Hg and 129.8 ± 13.3 mm Hg in the control and intervention groups, respectively (P = .0015). BP control was maintained in 61 (41.8%) control patients and 55 (67.1%) intervention patients (P = .0003). At 18 months post-intervention, systolic BP was 138.1 ± 20.4 mm Hg and 130.0 ± 16.0 mm Hg in the control and intervention groups, respectively (P = .023). BP control was maintained in 53 (36.3%) control patients and 55 (67.1%) intervention patients at 18 months post-intervention (P < .0001). A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease, and the differences between groups were still significant. BP control rates remained significantly higher following a physician-pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention. This model has the potential value as a useful long-term strategy to benefit patients with hypertension., (© 2011 Wiley Periodicals, Inc.)

Unlabelled: Numerous studies have demonstrated the value of team-based care to improve blood pressure (BP) control, but there is limited information on whether these models would be adopted in diverse populations. The purpose of this study was to evaluate whether a collaborative model between physicians and pharmacists can improve BP control in multiple primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control can be sustained. This study is a randomized prospective trial in 27 primary care offices first stratified by the percentage of underrepresented minorities and the level of clinical pharmacy services within the office. Each office is then randomized to either a 9- or 24-month intervention or a control group. Patients will be enrolled in this study until 2012. The results of this study should provide information on whether this model can be implemented in large numbers of diverse offices, if it is effective in diverse populations, and whether BP control can be sustained long term., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.

Study Objective: To assess blood pressure control after discontinuation of a physician-pharmacist collaborative intervention., Design: Comparative analysis of data of the patients who received the intervention versus a control group from a prospective, cluster-randomized, 9-month efficacy trial and the same patients' data 18 and 27 months after completion of the trial, abstracted from their medical records., Setting: Five primary care medical offices operated by a university health system., Patients: One hundred four patients with hypertension; 65 were in the intervention group, and 39 were in the control group., Measurements and Main Results: In the prospective study, patients were randomized to receive a physician-pharmacist collaborative intervention to improve blood pressure control or to the control group. Systolic and diastolic blood pressures were measured by a research nurse at baseline and at the end of the study (9 mo later). In the current study, data were abstracted for blood pressure and blood pressure control at 18 and 27 months (9 and 18 mo, respectively, after discontinuation of the study). At baseline, mean +/- SD systolic blood pressure was 152.5 +/- 9.5 and 150.1 +/- 9.6 mm Hg in the intervention and control groups, respectively (p=0.22). At 9 months, systolic blood pressure decreased to 124.5 +/- 10.7 and 132.0 +/- 15.1 mm Hg (p=0.0038 between groups), and blood pressure was controlled in 78.5% and 48.7% (p=0.0017) of patients in the intervention and control groups, respectively. By 18 months, systolic blood pressure had deteriorated to 131.0 +/- 12.2 and 143.3 +/- 17.5 mm Hg (p<0.001), and blood pressure control rates decreased to 53.9% and 30.8% (p=0.02). By 27 months, systolic blood pressure was 131.3 +/- 13.0 and 141.2 +/- 15.8 mm Hg (p=0.0008), and blood pressure control was 55.4% and 35.9% (p=0.05)., Conclusion: A sustained positive effect on blood pressure control was noted up to 18 months after discontinuation of a physician-pharmacist collaborative intervention, when compared with a control group. Blood pressure control did deteriorate at a similar rate in both the intervention and control groups, but the percentage of patients with controlled blood pressure remained significantly higher in the intervention group. These results suggest that continued interventions by pharmacists may be necessary to maintain high rates of blood pressure control, especially in those patients whose blood pressure begins to increase.

Background: Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control., Methods: This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring., Results: The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001)., Conclusions: A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management., Trial Registration: clinicaltrials.gov Identifier: NCT00201019.

Objectives: To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost., Data Sources/study Setting: Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures., Study Design: Experimental design and observational "as-treated" and instrumental variable (IV) methods., Data Collection/extraction Methods: Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts., Principal Findings: The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention., Conclusions: A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost.

Objective: To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults., Study Design: Experimental design with the hospital as the unit of randomization., Study Setting: Twelve acute care hospitals in the Midwest., Data Sources: (a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients., Data Collection: Data were abstracted from MRs and questions distributed to nurses and physicians., Principal Findings: The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001)., Conclusion: The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

Study Objective: To compare physician adherence to guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure for patients younger than 65 years of age with those aged 65 years and older, and to analyze whether factor groupings (subsets of criteria used to determine adherence) were predictive of blood pressure control., Design: Retrospective medical record review., Setting: Five university-affiliated family medicine and internal medicine outpatient clinics., Patients: One hundred seventy-nine patients (age range 21-85 yrs) with uncontrolled hypertension: 105 patients were younger than 65 years (nonsenior), and 74 patients were 65 years or older (senior)., Measurements and Main Results: Data abstracted from each patient's medical record were used to evaluate adherence to 17 process-of-care criteria, identified to assess physician adherence to the guidelines. A computer algorithm generated scores for each criterion as well as an overall adherence score. The relationship between the adherence score and blood pressure control was then examined. Separate factor analyses were conducted to ascertain differences in the way that the criteria were grouped. Factor scores were calculated for each patient, and the scores were evaluated in the context of blood pressure control. Guideline adherence scores were significantly higher for nonsenior patients than for senior patients (59.3% vs 56.1%, p=0.024). Blood pressure control rate was also higher, although not significantly, in nonseniors versus seniors (68.6% vs 56.8%, p=0.063). No factors in the senior group were significantly associated with blood pressure control, but one was significantly correlated in the nonsenior group (p<0.0001). It included diuretic therapy, adjusting a drug when a patient's blood pressure was uncontrolled, documentation of uncontrolled blood pressure in the medical record at the visit, documentation of the correct blood pressure goal, documentation of cardiovascular risk factors, and measurement of urine albumin level., Conclusion: Overall physician adherence to blood pressure guidelines was significantly higher for the nonsenior group than for the senior group. Similarly, control of blood pressure was better in the nonsenior group. However, no significant relationship between overall adherence scores and blood pressure control was found in either group. In nonseniors, one factor grouping was significantly correlated with blood pressure control. Future studies should evaluate the process-of-care criteria to determine if and how they are related to blood pressure control in senior patients.

This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) hypertension guidelines in 6 community-based clinics. Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria. Mean overall guideline adherence was 53.5% and did not improve significantly over time. Random-effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors, including age, minority status, comorbid conditions, and number of medications. A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence. Nonadherence was rated as justifiable for only 6.6% of the failed explicit criteria. In general, adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration.

Adherence to practice guidelines is frequently used as a measure of quality of care. Numerous studies have evaluated physician adherence to hypertension guidelines by prescription data, physician survey data, or medical record review. However, most have methodological limitations that might underestimate physician adherence. Accurate and meaningful characterization of adherence rests on evaluation of varied components of hypertension care, use of explicit validated performance measures, incorporation of implicit and explicit review, and linkage of process measures to blood pressure outcomes.

Objectives: To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population., Methods: Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults., Results: Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain., Conclusions: Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.

Internet technology holds potential as a valuable educational tool, but several challenges continue to impede its use. This article describes the use of a web-based course to educate staff nurses regarding evidence-based acute pain management practices for older adults. Specific areas highlighted include: the steps involved in creating the web-based course; the materials and support required to disseminate the course; the challenges encountered in promoting use of the course; and responses to and evaluations of the course. The authors' experiences provide knowledge to assist other healthcare professionals on the use of a web-based course to educate staff nurses.

As part of a multisite study funded by the Agency for Healthcare Research and Quality, the medical records of older adults with a hip fracture were abstracted for acute pain assessment and treatment practices. Of the 709 records reviewed, 8 patients did not have an opioid administered during the first 72 hours after admission to a non-intensive patient care unit. Using a case study approach, this article examines demographic characteristics, pain assessment, and analgesic administration for these 8 patients to illustrate specific practice problems that occur in managing acute pain in older adults. Pain intensity was documented infrequently. All 8 patients had a physician order for some type of analgesic, and 7 of the 8 had an order for an opioid analgesic. Yet none received an opioid during the first 72 hours of care on a general medical-surgical unit, and one patient received no analgesia of any kind. The medical records of these hip fracture patients indicate that acute pain was underassessed and undertreated. Provision of quality pain management will require that nurses address the specific practice behaviors identified in the article and correct problems where they exist. Key strategies that can be used to improve pain management practices include implementation of standardized assessment tools and pain flow-sheets, audit and feedback of pain management data with staff, use of pain management opinion leaders and change champions, and incorporation of research-based pain management practices into performance-evaluation criteria.

This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.